Summary

Faltering Growth (formerly known as Failure to Thrive) is a descriptive term, not a specific diagnosis. It describes a child whose weight gain is significantly below that expected for their age and gender. It is a common paediatric presentation, accounting for 5-10% of referrals. The etiology is split into Non-Organic (Psychosocial/Feeding/Neglect) and Organic (disease). In developed countries, >90% of cases are Non-Organic (Feeding difficulties).

Definition (NICE NG75)

• Weight Fall: A sustained drop down through two or more major centile spaces (e.g., from 50th -> 9th).
• Low Weight: Weight below the 2nd centile for age (if not consistent with family/ethnicity).
• Deceleration: Weight centile is more than 2 centile spaces below Height centile.

Clinical Pearls

The "Calorie Gap": Fundamentally, all faltering growth is a mismatch between energy IN and energy OUT.

• Non-Organic: Not enough goes IN (Poverty, Refusal, Neglect).
• Organic: Too much goes OUT (Malabsorption) or Burned (Cardiac failure/Cancer).

Don't Over-investigate: The vast majority of well-looking children with faltering growth need a Dietitian, not an MRI scanner. "Testing for everything" is traumatic and low-yield.

Growth requires a positive energy balance. Failure occurs via 3 mechanisms:

This is the most important "test". Spend 20 minutes here.

Volume & Frequency

• Breast: Length of feed? Frequency? Maternal supply? Pain?
• Bottle: Volume taken? Frequency? How do you mix it? (Crucial: Over-diluting formula to "stretch" it is a sign of poverty).
• Solids: What textures? 3-day food diary?

Behaviour

• Mealtime Battle: Is the child force-fed? Is there screaming/crying?
• Grazing: Does the child snack on crisps/juice all day (killing appetite for meals)?
• Sensory: Avoids specific textures (Autism spectrum)?

Red Flags for Organic Disease

• Vomiting: Severe GORD, Pyloric Stenosis.
• Stool: Loose/Greasy/Foul (Malabsorption). Blood (CMPA/IBD).
• Systemic: Fever, lethargy, night sweats.
• Development: Regression or delay.

Plotting Growth (The "Roadmap")

• Weight: Core metric.
• Height/Length: Chronic malnutrition stunts height. Acute malnutrition spares height ("Wasting" vs "Stunting").
• Head Circumference: Spared until last ("Brain Sparing"). If Head Circumference is dropping, it is SEVERE or Neurological/Syndromic.

Physical Signs

• Dysmorphism: Syndromic features (e.g., Turner's, Down's, Silver-Russell).
• Skin: Eczema (Atopy/CMPA), poor turgor (dehydration), bruises (abuse).
• Abdomen: Distension (Coeliac/CF), Organomegaly.
• Cardiac: Murmurs (CHD).
• Neurological: Tone/Power (Cerebral Palsy).

Step 1: Optimise Behaviour (Dietitian + Health Visitor)

• Routine: 3 meals, 2 snacks. No grazing. Water only between meals.
• Environment: Eat as a family. No TV/iPad. Positive reinforcement. Messy play allowed.
• Stop Force Feeding: It creates aversion.

Step 2: "Food Fortification" (The "Secret Calories")

Add calories without adding volume (Volume is the enemy of the small tummy).

• Add Butter/Cheese/Cream to mash/sauces.
• Add Oil to pasta.
• Use Full Fat milk/yoghurt. (No skimmed milk under 5).

Step 3: High Energy Prescriptions

If food fortification fails (after 1 month):

• Infants: High Energy Formula (e.g., Infatrini, Similac High Energy). 1kcal/ml (Standard is 0.67kcal/ml).
• Children: Sip Feeds (e.g., PaediaSure, Fortini). Used as "top-ups" after meals, not meal replacements.

Step 4: Medical Management

• GORD: If vomiting is limiting intake -> PPI (Omeprazole) trial.
• Iron: Treat anaemia vigorously (improves appetite).

Step 5: Enteral Feeding (The Last Resort)

• NG Tube: Short term crisis.
• PEG (Gastrostomy): Long term inadequacy (e.g., severe Cerebral Palsy, CF).

Faltering growth can be a sign of Neglect.

• Clues:
  • Child gains weight rapidly in hospital/foster care but loses it at home.
  • Unexplained injuries.
  • Poor hygiene/dental care.
  • Parents detached or hostile.
• Action: If concerned, careful documentation and referral to Social Services is mandatory. "The child's welfare is paramount."

• Primary Care: Mild cases. Monthly weight checks.
• Paediatrics: Refer if:
  • Red flags (Organic disease).
  • Failed "Food First" management.
  • Safeguarding concerns.
• Admission: Rarely needed. Only for:
  • Severe dehydration/malnutrition requiring NG feeding.
  • Safeguarding crisis.

"My child won't eat!"

• Normal Toddler Behaviour: Toddlers are "Neophobic" (scared of new foods). This is evolutionary (don't eat poisonous berries).
• The Division of Responsibility:
  • Parent's Job: Decide What, Where, and When the child eats.
  • Child's Job: Decide How much and Whether they eat.
• Trust: Do not force. A healthy child will not starve themselves.

1. Calculating Energy Requirements (Schofield Equation)

Ideally, use a chart. But roughly:

• 0-3 months: 110-120 kcal/kg/day
• 3-6 months: 100 kcal/kg/day
• 6-12 months: 90-100 kcal/kg/day
• 1-3 years: 90 kcal/kg/day (BUT total calories increase with size)

Catch-Up Requirement: To catch up, a child needs more than the average for their current weight. They need the calories for their ideal weight (50th centile for height).

Catch-Up Formula:

Requirement (kcal/kg) = (RDA for Age x Ideal Weight for Height) / Actual Weight

2. Formula Milk Composition

Fabricated or Induced Illness (FII) (Munchausen's by Proxy)

• Mechanism: Caregiver exaggerates or causes symptoms in the child to gain medical attention.
• Relevance to Faltering Growth:
  • Withholding food.
  • Diluting formula.
  • Administering laxatives (diarrhoea/weight loss).
  • Tampering with feeds (e.g., adding salt).
• Red Flags:
  • Discrepancy between reported symptoms and observation (e.g., "He vomits all day" but thrives in hospital).
  • Treatments "don't work" (Resistance to therapy).
  • Symptoms resolve when parent is absent.
• Investigation: Carefully coordinated MDT. Covert surveillance (police).

Case 1: The "Happy Wheezer" (Organic)

• Presentation: 6-month-old. Weight dropped 75th -> 9th. "Happy", smiles.
• History: Loose stools "always". Frequent chest infections.
• Exam: Hyperinflated chest. Clubbing? (Hard to see in babies).
• Diagnosis: Cystic Fibrosis.
• Treatment: Creon, High Calorie Milk, Phyisotherapy. Resumed growth.

Case 2: The "Grazer" (Non-Organic)

• Presentation: 2-year-old. Weight 9th centile. History "He won't eat dinner".
• Diet History: drink 4-5 beakers of squash/juice per day. Eats crisps packet at 10am and 2pm.
• Diagnosis: Toddler Diarrhoea / Poor Feeding Routine.
• Treatment:
  1. Stop the squash (calories but no nutrition, stops appetite).
  2. Stop the snacks.
  3. Hunger at mealtime returns.
  4. Weight gain.

• Bone Age: X-ray of left wrist. Estimates "Biological" age vs "Chronological" age. Delayed in constitutional delay and hypothyroidism.
• Catch-up Growth: Rapid growth velocity (steep line upwards) following correction of malnutrition.
• Centile Crossing: Crossing 2 major lines (e.g., 50 -> 25 -> 9). 5% of normal children might do this, but it warrants review.
• Constitutional Delay: "Late bloomer". Short child, delayed puberty, delayed bone age, but normal growth velocity (parallel to centiles). Parents were late bloomers.
• EHF: Extensively Hydrolysed Formula.
• Kwashiorkor: Protein-energy malnutrition with Oedema (swollen belly). Rare in developed world.
• Marasmus: Severe wasting (skin and bone).
• Mid-Parental Height (MPH): Calculation to predict target adult height.
  • Boys: (Dad + Mum + 13) / 2
  • Girls: (Dad + Mum - 13) / 2
• Rickets: Vitamin D/Calcium deficiency causing soft bones and poor growth.

1. NICE NG75. Faltering growth: recognition and management of faltering growth in children. 2017.
2. WHO Multicentre Growth Reference Study Group. WHO Child Growth Standards. 2006.
3. Shields B, et al. Faltering growth in children: a logical approach to management. BMJ. 2012.
4. Wright CM, et al. Practice guide: weight faltering and failure to thrive in infancy. J Paediatr Child Health. 2000.
5. Goyal N. The "Food First" approach to paediatric malnutrition. Paediatric Care. 2023.
6. Larson-Nath C, et al. Failure to Thrive: A prospective study of inpatient management. Hosp Pediatr. 2018.
7. Royal College of Paediatrics and Child Health (RCPCH). UK-WHO Growth Charts Resources.
8. Vandenplas Y, et al. Guidelines for the diagnosis and management of Cow's Milk Protein Allergy. Arch Dis Child. 2007.
9. Golden MH. The evolution of nutritional management of acute malnutrition. Indian Pediatr. 2010.
10. Batchelor L. Nutrition in Cystic Fibrosis. Nutr Clin Pract. 2020.

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